Amid all the turbulence over the future of the Affordable Care Act, one facet continues unchanged: President Trump’s administration is penalizing more than half the nation’s hospitals for having too many patients return within a month.

Medicare is punishing 2,573 hospitals, just two dozen short of what it did last year under former President Obama, according to federal records released Aug. 2. Starting in October, the federal government will cut those hospitals’ payments by as much as 3 percent for a year.

Medicare docked all but 174 of those hospitals last year as well. The $564 million that the government projects to save also is roughly the same as it was last year under Obama.

High rates of readmissions have been a safety concern for decades, with one in five Medicare patients historically ending up back in the hospital within 30 days. In 2011, 3.3 million adults returned to the hospital, running up medical costs estimated at $41 billion, according to the federal Agency for Healthcare Research and Quality.

The penalties, which begin their sixth year in October, have coincided with a nationwide decrease in hospital repeat patients. Between 2007 and 2015, the frequency of readmissions for conditions targeted by Medicare dropped from 21.5 percent to 17.8 percent, with the majority of the decrease occurring shortly after the health law passed in 2010, according to a study last year in the New England Journal of Medicine conducted by Obama administration health-policy experts.

Some hospitals began giving impoverished patients free medications that they prescribe for their recovery, while others sent nurses to check up on patients seen as most likely to relapse in their homes. Readmissions dropped more quickly at hospitals potentially subject to the penalty than at other hospitals, another study found.

“The sum of the evidence really suggests that this program is helping people,” said Dr. Susannah Bernheim, the director of quality measurement at the Yale/Yale-New Haven Hospital Center for Outcomes Research and Evaluation, which measures readmission rates for Medicare.

But the pace of these reductions has been leveling off in the past few years, indicating that the penalties’ ability to induce improvements may be waning.

“Presumably, hospitals made substantial changes during the implementation period but could not sustain such a high rate of reductions in the long term,” the New England Journal article said.

An analysis by Bernheim’s group found no decrease in the overall rate of readmissions between 2012 and 2015, although small drops in the medical conditions targeted by the penalties continued.

“We have indeed reached the limits of what changes in how we deliver care will allow us to do,” said Nancy Foster, vice president for quality at the American Hospital Association. “We can’t prevent every readmission. It could be that there is further room for improvement, but we just don’t know what the technique is to make that happen.”

The Hospital Readmissions Reduction Program was created through a section of the ACA designed to use the purchasing power of Medicare to reward hospitals for higher quality. Those penalties, along with other ones aimed at improving hospital care, have been spared the partisan rancor over the law, and they would have continued under the GOP repeal proposals that stalled in Congress. But they have also been largely ignored.

Dr. Ashish Jha, a professor at the Harvard T.H. Chan School of Public Health, said the fight over abolishing the Affordable Care Act has drowned out talk about how to make the health care system more effective. “We’ve spent the last six months fighting about how we’re going to pay for health insurance, which is one part of the ACA,” he said. “There’s been almost no discussion of the underlying health care delivery system changes that the ACA ushered in, and that is more important in the long run to be discussing because that’s what’s going to determine the underlying costs and outcomes of the health system.”

The readmission penalties are intended to neutralize an unintended incentive in how Medicare pays hospitals that had profited from return patients. Medicare pays hospitals a lump sum for a patient’s stay based on the nature of the admission and other factors. Since hospitals generally are not paid extra if patients remain longer, they seek to discharge patients as soon as is medically feasible. If the patient ends up back in the hospital, it becomes a financial benefit as the hospital is paid for that second stay, filling a bed that would not have generated income if the patient had remained there continuously.

Because of how the readmission-penalty program was designed, it is not surprising that the new results are so similar to last year’s. As before, Medicare determined the penalties based on readmissions of the same six types of patients: those admitted for heart attacks, heart failure, pneumonia, chronic lung disease, hip or knee replacements or coronary artery bypass graft surgery. Hospitals were judged on patients discharged between July 2013 and June 2016. Because the government looks at a three-year period, two of those years were also examined in determining last year’s penalties.

This year, the average penalty will be 0.73 percent of each payment Medicare makes for a patient between Oct. 1 and Sept. 30, 2018, according to a Kaiser Health News analysis. That too was practically the same as last year. Forty-eight hospitals received the maximum punishment of a 3 percent reduction. Medicare did not release hospital-specific estimates for how much lost money these penalties would translate to.

More than 1,500 hospitals were exempted from penalties this year as required by law. Those include hospitals treating veterans, children and psychiatric patients. Critical access hospitals, which Medicare also pays differently because they are the only hospitals in their areas, were excluded. So were Maryland hospitals because Congress has given that state extra leeway in how it distributes Medicare money.

Of the 3,241 hospitals whose readmissions were evaluated, Medicare penalized four out of five, KHN’s analysis found. That is because the program’s methods are not very forgiving: A hospital can be penalized even if it has higher than expected readmission rates for only one of the six conditions that are targeted. Every non-excluded hospital in Delaware and West Virginia will have their reimbursements reduced. Ninety percent or more will be punished in Arizona, Connecticut, Florida, Kentucky, Massachusetts, Minnesota, New Jersey, New York and Virginia. Sixty percent or fewer will be penalized in Colorado, Kansas, Idaho, Montana, Oregon, South Dakota and Utah.

Since the readmission program’s structure is set by law, the administration cannot make major changes unilaterally, even if it wanted to.

Congress last year instructed Medicare to make one future alteration in response to complaints from safety-net hospitals and major academic medical centers.

They have objected that their patients tended to be lower income than other hospitals and were more likely to return to the hospital, sometimes because they didn’t have a primary care doctor and other times because they could not afford the right medication or diet. Those hospitals argued that this was a disadvantage for them since Medicare bases its readmission targets on industry-wide trends and that it hurt them financially, depriving them of resources they could use to help those same patients.

Bernheim noted that despite those complaints, safety-net hospitals have shown some of the greatest drops in readmission rates. In October 2018, Medicare will begin basing the penalties on how hospitals compared to their peer groups with similar numbers of poor patients. Akin Demehin, director of policy at the hospital association, said, “We expect the adjustment will provide some relief for safety-net hospitals.”

Medicare is planning to release two other rounds of recurring quality incentives for hospitals later this year. One gives out bonuses and penalties based on a mix of measures, with Medicare redistributing $1.9 billion based on how hospitals perform and improve. The other, the Hospital-Acquired Condition Reduction Program, cuts payments to roughly 750 hospitals with the highest rates of infections and other patient injuries by 1 percent.

Michael I. Harrison, Ph.D., of the Agency for Healthcare Research and Quality, writes in NEJM Catalyst about the limitations of Lean-based approaches to healthcare institutions’ management.

He writes that “according to current research, Lean promises more than it has delivered. It is possible that published research studies are lagging practice, where there are some reports of Lean-driven breakthroughs in quality and value and even Lean-based culture change. But a positive publication bias may actually be leading the research literature to overestimate Lean’s potential.’’

Among his other observations:

“To ensure appropriate care for chronically ill patients, and to promote population health, organizations need to redefine some traditional operating objectives and performance standards and develop new or radically redesigned care processes, such as team-based primary care. As Lean experts and users concentrate on making current processes more efficient, they may devote insufficient attention and energy to developing new goals and care delivery designs.

“Except in tightly integrated systems, coordination of medical care requires cooperation across fragmented medical services. Health promotion calls for joint action by medical, social, and educational services. It takes time and concerted effort to build teams that bridge boundaries between care sites and entire organizations. But Lean projects typically rely on teams made up of members of the same organization, who already share objectives and operating assumptions.

“Radically transforming taken-for-granted assumptions, values, and work procedures goes far beyond targeting selected processes for improvement. To change culture, leaders must articulate an overarching organizational change strategy and align diverse programs and improvement initiatives with that strategy. Strategic and behavior change must be implemented and reinforced through the appropriate use of performance measures, incentives, training, and staffing. Lean thinkers call for culture change, but popular Lean improvement techniques alone do not provide sufficient change levers to promote it.’’

The federally affiliated Health Care Payment Learning and Action Network (HCPLAN), looking to advance value-based care and save payers money, advocates using bundled-payment systems to address the high-volume admissions related to maternity and newborn care. As well it would: Maternal and newborn stays together represent more than 20 percent of all hospital stays, says the Agency for Healthcare Research and Quality.

HCPLAN is a public-private collaborative network trying to reach the federal government’s goal that 50 percent of all healthcare payments be via alternative (value-based) payment models by 2018. The network’s clinical-episode payment work group has named maternity care, elective knee and hip replacement and coronary-artery disease treatment (mostly involving bypass surgery) as priorities for episode-based payments.

Work group members see many ways to improve care and cut costs in maternity and newborn care. Consider that the U.S. cesarean-section rate is high — more than 30 percent of births, says the World Health Organization — despite the expense and potential danger to mother and baby. Cesarean deliveries are lucrative for physicians and hospitals.

Further, more than 9 percent of births are pre-term, including many early elective deliveries, which of course means more neonatal intensive care. All this with U.S. infant-mortality rates higher than in most of the Developed World.

As Hospitals & Health Networks reports, Geisinger Health Plan, in central Pennsylvania, has used bundled payments approach for obstetrics for six years — and with good results, John B. Bulger, D.O., Geisinger’s chief medical officer for population health, told H&HN.

“Early elective deliveries almost immediately dropped to zero when the obstetrics department started to focus on processes of care. That resulted in fewer C-sections and reduced NICU use. ‘It is a win-win-win because the baby is healthier, happier, the mother is healthier and happier, and the population is healthier and happier because it is less costly to the system,’ he says.”

“Geisinger’s perinatal care bundle, available only for low-risk pregnancies, includes all prenatal, labor and delivery, and postpartum care for the mother only; the baby’s care is not covered in the bundle.”

H&HN says that “despite Geisinger’s success, its particular approach has not been widely adopted. A handful of payers and health systems are experimenting with maternity care bundles, but most are waiting for somebody else to figure out best practices. The first challenge is the sheer length of the episode.”

‘We feel pretty strongly that an episode should include prenatal, postpartum and — ideally — 30 days of newborn care,” Brynn Rubinstein, senior manager for Transform Maternity Care at the Pacific Business Group on Health, told H&HN. “It’s really hard to navigate all of the providers that a woman and baby might see, and all of the other conditions related to pregnancy, or unrelated to pregnancy, and how to include those in the episode.”

”Rubinstein, who is working with plans and purchasers to implement the recommendations outlined in HCPLAN’s white paper on maternity care episode payments, says purchasers are tired of the variation in cost and quality of maternity and newborn care.”

‘“While there are many obstacles to navigate, they are all challenges that can be overcome. It may take a few years, but they can absolutely be overcome, and we need to start today.”

Sepsis, a life-threatening infection often acquired during patients’ hospital stays, remains the most costly condition for hospitals to treat, according to the latest data analyzed by the Agency for Healthcare Research and Quality.

The agency said that patients with sepsis took up $23.7 billion in hospital costs, or about 6.2 percent of America’s hospital bill, but sepsis patients were only 3.6 percent of all hospital stays.

The numbers are depressing. However, sepsis is one of things that revised clinical approaches can do a lot to reduce.

Here’s a Bloomberg look at a new program called Communication and Optimal Resolution, or Candor, being promoted by the federal Agency for Healthcare Research and Quality (AHRQ). It’s meant to save hospitals money on malpractice lawsuits while encouraging more rigorous scrutiny of what went wrong and to help patients, families and clinicians cope with traumatic events.

Bloomberg reports: “Hospitals are supposed to complete the investigation within about two months and share the findings with the patients. At that time, they’ll discuss how to prevent future incidents. If the inquiry determines the harm resulted from a breach in the standard of care, something a lawyer might call negligence, the hospital and patient will negotiate financial compensation.”

As thius

As this Bloomberg article explains it: “Under Candor, when a case involving patient harm is identified, trained hospital staff tell victims or their families what happened within one hour. At the same time, they reach out to caregivers. The hospital stays in touch with patients and relatives as the event is investigated and interviews them about what happened. It also pauses its billing process so injured patients or grieving families aren’t dealing with the cost of care received, an emotionally fraught experience when that ‘care’ injured or killed a loved one.”

CMS has put out a request for proposals to develop Hospital Improvement and Innovation Networks (HIINs) to improve patient safety and reduce hospital readmissions.

The goal is to reduce overall patient harm by 20 percent and 30-day readmissions by 12 percent from a 2014 baseline.

Part of the Quality Improvement Organization initiative, HIINs will further work begun by the Hospital Engagement Networks under the Partnership for Patients initiative.

Progress has been made. A December 2015 report by the Agency for Healthcare Research and Quality found that preventable adverse events had fallen 39 percent from 2010, which meant 2.1 million fewer patients harmed, 87,000 deaths prevented and about $20 billion saved over the four-year period.

The networks will use the experience of hospital associations, health systems and others with experience in hospital-quality improvement to help spread evidence-based best practices.

“Now could be an opportune moment to create a national public–private partnership to propel progress. The Department of Veterans Affairs and the Agency for Healthcare Research and Quality have made commitments to improving diagnosis, but the Centers for Disease Control and Prevention, the National Institutes of Health, and the ONC also have interests that intersect with patient safety and could contribute to research and implementation initiatives for elucidating and reducing diagnostic errors. On the private side, a movement is being led by the nonprofit Society to Improve Diagnosis in Medicine, …which petitioned the IOM to study this issue and aims to spearhead a national coalition of professional societies and other interested parties to translate the recommendations into action.

“For the past 15 years, the patient-safety movement has focused on treatment-related harms. But interactions that are too brief to permit clinicians to listen to patients, productivity pressures, and reimbursement systems that don’t adequately support clinicians’ cognitive work are highlighting additional safety issues. ‘Improving Diagnosis in Health Care’ restores balance to the patient-safety quest by calling attention to diagnosis, the other half of medicine. We are optimistic that the report will spark a renaissance of interest in improving diagnosis and reducing patient harm from diagnostic error.”

When Charles Thompson of Greenville, S.C., checked into the hospital one July morning in 2011, he expected a standard colonoscopy. He never anticipated how wrong things would go.

Partway through, a doctor emerged from the operating room to tell Thompson’s wife, Ann, that there had been complications: His colon may have been punctured. He needed emergency surgery.

Thompson, now 61, almost died on the operating table after experiencing cardiac distress. His right coronary artery required multiple stents. He also relies on a pacemaker. “He’s not the same as before,” said Ann Thompson, 62. “Our whole lifestyle changed — now all we do is sit at home and go to church. And that’s because he’s scared of dying.”

When things like this happen, questions arise: Who’s responsible? If treatment makes things worse — meaning that a patient needs more care than expected — who pays?

It depends.

Despite provisions in the Affordable Care Act that put added emphasis on quality of care, entering the hospital still carries risk. Whether because of mistakes, infections or plain bad luck, those who go in don’t always come out better. More than 400,000 Americans die annually in part because of avoidable medical errors, according to a 2013 estimate published in the Journal of Patient Safety.

In 2008, the most recent year studied, medical errors cost the country $19.5 billion, most of which was spent on extra care and medication, according to another report. If a problem such as Thompson’s stemmed from negligence, a malpractice lawsuit may be an option. But lawyers who collect only when there’s a settlement or a victory may not take on a case unless it’s exceptionally clear that the doctor or hospital was at fault.

That creates a Catch-22, said John Goldberg, a professor at Harvard Law School and an expert in tort law. “We’ll never know if something has happened because of malpractice,” he said, “because it’s not financially viable to bring a lawsuit.”

That leaves the patient responsible for extra costs. Ann and Charles Thompson maintain that he experienced an avoidable error. The hospital denied wrongdoing, she said, but the physician’s notes indicated that they had been advised of the risks of the procedure, including injury to the colon.

The Thompsons tried pursuing a lawsuit but couldn’t find a lawyer who would take the case. The hospital and the doctor declined to comment, with the hospital citing patient privacy laws. Because of his heart problem, which led to the loss of his specialized driver’s license, Thompson lost his truckdriving job. He lost the health insurance he had through his job, depriving him of help in paying for follow-up care.

The couple paid close to $600,000 out of pocket, depleting their life savings. They struggled to pay other bills until Thompson was awarded disability benefits, his wife said. “You would expect if [health-care providers] make the mistake, they would make you whole,” said Leah Binder, president of the Leapfrog Group, a nonprofit organization that grades hospitals on their record of preventing errors, injuries, accidents and infections. “But that is not what happens. In health care, you pay and you pay and you pay.”

There’s no single rule for how hospitals handle the cost of care when patients have bad outcomes and fault is disputed, said Nancy Foster, vice president for quality and patient safety at the American Hospital Association. Some hospitals have rules requiring that a patient be told right away if something happened that shouldn’t have and, to the best of the institution’s knowledge, why.

Typically, those rules stipulate that if the hospital finds that it erred, the necessary follow-up care is free. Hospitals may not have an obvious financial interest in admitting guilt, though research suggests that patients are less likely to sue when hospitals are transparent about medical mishaps.

“If the [need for further] care was preventable, we’re waiving bills,” said David Mayer, vice president of quality and safety for MedStar Health, which operates 10 hospitals in the Baltimore/Washington area.

Virginia’s Inova Health System has a similar policy, said spokeswoman Tracy Connell. Most hospitals don’t have such rules, said Julia Hallisy, a patient-safety advocate from California.

That may change: A number of professional and safety groups are urging more hospitals to adopt them. Supporters include the American College of Obstetricians and Gynecologists, the American Medical Association, Leapfrog, the National Quality Forum and the Joint Commission, which accredits many health-care organizations. The federal Agency for Healthcare Research and Quality is also on board.

But even when they tell patients that something went wrong, hospitals may say it was unavoidable. Then, patients often pay for the consequences, directly or through their insurance. Determining error can be straightforward, Mayer said, in such instances as misdiagnosis or operating on the patient’s left leg when his problem was with his right leg.

Other times, providers follow correct procedures but things go wrong. Then, hospitals can deny culpability. “Some things happen, and it’s hard to tell if it could truly have been avoided,” Binder said. If hospitals don’t agree to pay for unexpected care, employers might push them to do so because absorbing such costs might eat into the firm’s profits.

On average, a privately insured patient cost about $39,000 more — $56,000 vs. $17,000 — in hospital bills when surgery led to complications than when it did not, according to a 2013 study in the Journal of the American Medical Association.

People with employer-based insurance — 147 million Americans this year — who have experienced complications or otherwise gotten worse while in the hospital should contact their benefits offices, especially if they can show hospital error, Binder said. If that doesn’t pan out, insurance plans may step in.

When insurers add hospitals to their networks, they sometimes stipulate how to handle certain errors. For some mistakes, the hospital may provide necessary follow-up care for free, part of a “bundled payment,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group. For that to apply, complications must clearly stem from bad treatment. In other situations, patients can complain through the insurer, which should work with the hospital to determine who’s responsible.

Patients, Krusing said, shouldn’t pay for what’s out of their control. And if the hospital doesn’t provide financial assistance, insurance should cover these unexpected expenses once the patient has met his or her deductible.

“Patients don’t normally think about these issues — and who would? They don’t think of any of these issues until they’re right in the middle of it,” patient-safety advocate Hallisy said. “At that moment, they’re completely shocked and overwhelmed to think that this is how this works.”